With political changes also come regulation changes. Though surprise medical billing has long been an issue, Congress recently passed HR 3630 containing the “No Surprises Act”, to remedy the problem. This latest bill applies to all group and individual health plans, with an effective date of January 2022. Among other things, this regulation requires that provider directories be updated on a regular basis, every 90 days.

Healthcare Provider Profiles – A Continuing Challenge

Providers move offices, stop accepting patients and leave the program – causing inaccuracies in the provider directory. A study from the American Journal of Managed Care found provider directory addresses have a 30% inconsistency rate when a common provider is in the same company’s health plan networks across markets.[1] Other data indicates that 40% of provider records have missing or inaccurate information.[2]

This type of inaccuracy can cause problems for members. In one study, About half of physicians (52 percent) say at least once per month their patients encounter health insurance coverage issues due to inaccurate information included in network directories.[3] Misleading information can cause member dissatisfaction, potentially reducing HEDIS measurements and revenue.

The No Surprises Act will be enforced with penalties starting in 2022, less than a year away. Organizations need to create a plan now to manage the required provider directory maintenance.

How You Can Efficiently Update Your Provider Directory

It is a difficult task to get providers to give an accurate attestation. There are other ways to confirm the data in your healthcare provider profiles. Ideally, you can supplement provider profiles with data that is accurate and already available. Another option is to have a service verify provider information for you. Regardless of what you do, it’s going to be an investment – one that can help you improve profitability with:

  • Audit defense – Providing proof that your organization is doing its due diligence to maintain accurate records
  • Stable HEDIS measures and overall performance – Providing a good member experience
  • Accurate payments – Avoiding the cost of paying for bills that were charged as out-of-network when the provider profile said in-network

The solution is having the right data. Trying to correct it yourself is very costly and requires a heavy operational lift from your organization. But there are solutions available now to help you optimize your provider data and revenue.

For more information, visit our provider data quality page or call 1-866-396-7703.


[1] American Journal of Managed Care

[2] Based on internal data analysis conducted by LexisNexis.

[3] Survey reveals need for accurate network directories